Anatomy of the superior petrosal veins and their exposure and management during petrous apex meningioma surgery using the lateral suboccipital retrosigmoid approach

We present the case of a 50-year-old female with a 1-year history of right-side facial numbness, as well as an electric shock-like sensation on the right-side of the face and tongue. She was previously diagnosed with vertigo and trigeminal neuralgia. MRI was obtained showing a large right cerebellopontine angle mass. A retrosigmoid approach was performed and total removal was achieved after dissection of tumor from brainstem and cranial nerves IV, V, VI, VII and VIII. Pathology confirmed the diagnosis of a meningioma (WHO Grade I). The patient was discharged neurologically intact on the third postoperative day free of complications.The video can be found here: http://youtu.be/-tR0FtMiUDg.

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Petrous Apex Meningioma with Extension into Meckel's Cave: Resection using a Retrosigmoid Intradural Suprameatal Approach

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1676996 ◽

2019 ◽

Vol 80 (S 03) ◽

pp. S300-S301

Author(s):

Stephan A. Munich ◽

Jacques J. Morcos

Keyword(s):

Trigeminal Nerve ◽

Retrosigmoid Approach ◽

Petrous Apex ◽

Middle Fossa ◽

Meckel’S Cave ◽

Meckel's Cave ◽

Grade Ii

The retrosigmoid intradural suprameatal approach was first introduced in 1983 by Samii et al, as a modification of the classic retrosigmoid approach intended to open Meckel's cave, exposing the trigeminal nerve and access the middle fossa.1 The area of bone resected in this approach is similar to that removed in a Kawase's approach.2 Whereas the direction of drilling in a Kawase's approach is from anterior and superior, it is from posterior and inferior in the retrosigmoid intradural suprameatal approach. Seoane and Rhoton quantified the exposure of Meckel's cave, finding that this approach allowed access, on average, to the posterior 10.3 mm of Meckel's cave.3 This was confirmed by Chanda and Nanda who found that suprameatal drilling resulted in a mean gain of exposure of the trigeminal nerve of 10.7 mm.4 In this video, we present the case of a patient when an enlarging petrous apex meningioma with extension into Meckel's cave (Fig. 1). The patient underwent a retrosigmoid intradural suprameatal approach to achieve a Simpson's grade II resection. This approach was ideally suited for this case to obtain access to tumor located at the petrous apex and within Meckel's cave (Fig. 2). Without access to Meckel's cave provided in this approach a significant portion of tumor would have remained in situ.The link to the video can be found at: https://youtu.be/eNldkF4a_OI.

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Piezosurgery-, neuroendoscopy-, and neuronavigation-assisted intracranial approach for removal of a recurrent petrous apex cholesteatoma: technical note

Journal of Neurosurgery Pediatrics ◽

10.3171/2017.8.peds17327 ◽

2018 ◽

Vol 21 (3) ◽

pp. 322-328 ◽

Cited By ~ 3

Author(s):

Juergen Grauvogel ◽

Christian Scheiwe ◽

Waseem Masalha ◽

Tanja Grauvogel ◽

Jan Kaminsky ◽

...

Keyword(s):

Facial Nerve ◽

Complete Removal ◽

Technical Note ◽

Retrosigmoid Approach ◽

Petrous Apex ◽

Nerve Function ◽

Canal Wall ◽

Bone Removal ◽

Piezoelectric Surgery ◽

Intraoperative Visualization

Current approaches for resection of petrous bone cholesteatomas (PBCs), such as canal wall up (closed) and canal wall down (open) mastoidectomies, in the pediatric population present recurrence rates ranging between 17% and 70% with a high rate of postoperative complications involving hearing loss and facial nerve weakness. This technical note illustrates an alternative intracranial approach that was used in combination with the techniques of piezoelectric surgery, neuroendoscopy, and neuronavigation for safe and effective removal in a difficult pediatric case of recurrent PBC.The third recurrence of a PBC in a 14-year-old girl was diagnosed by CT and MRI. A retrosigmoid approach gave access to the petrous apex, allowing for the safe and complete removal of the lesion and decompression of the facial nerve and internal carotid artery. The intraoperative implementation of piezoelectric surgery, neuronavigation, neuroendoscopy, and neuromonitoring ensured better intraoperative visualization, safer bone removal, and preservation of nerve function, facilitating a macroscopically total resection of the pathology without additional neurological damage of the adjacent tissues.Cholesteatoma extension could be clearly verified by intraoperative neuronavigation. Neuroendoscopy and piezoelectric surgery provided good support in the safe bone removal in close vicinity to neurovascular structures and in full vision inside the cholesteatoma cavity beyond the line of sight of the microscope. Hearing and facial nerve function could be preserved.The presented intracranial retrosigmoid approach combined with multiple intraoperative assisting techniques proved to be effective for the safe and complete removal of recurrent PBC, providing excellent intraoperative visualization and the possibility of preserving cranial nerve function.

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